AAOS Sports Medicine MCQs: Knee & Rotator Cuff Prep

Question 1

Closure of the rotator cuff interval results in elimination of which direction of shoulder instability?

Explanation

The rotator cuff interval consists of the superior glenohumeral and coracohumeral ligaments. Injury to this ligament complex leads to posteroinferior shoulder instability. Tightening of these tissues through surgical means has been shown to result in a significant reduction in posteroinferior translation of the humerus in relation to the glenoid. Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66. O'Brien SJ, Schwartz RS, Warren RF, et al: Capsular restraints to anterior-posterior motion of the abducted shoulder: A biomechanical study. J Shoulder Elbow Surg 1995;4:298-308.

Question 2

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?

Explanation

The leg and trunk provide a stable base for arm motion, supply rotational momentum for force generation, and generate 50% to 55% of the total force and kinetic energy in the tennis serve. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 47. McClure PW, Michener LA, Sennett BJ, et al: Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg 2001;10:269-277.

Question 3

A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. A radiograph is shown in Figure 21. Management should consist of

Sports Medicine Board Review 2007: High-Yield MCQs (Set 4) - Figure 1

Explanation

The radiograph reveals an increased distance between the scaphoid and the lunate, which is indicative of scapholunate disassociation. A ring sign is also present, which represents the distal pole of the scaphoid viewed end on in a palmarly flexed position. In the acute setting, the scapholunate can be repaired. Open repair and percutaneous pinning is the treatment of choice. Dorsal capsulodesis is performed in the chronic setting if such an injury is initially missed. Cohen MS: Ligamentous injuries of the wrist in the athlete. Clin Sports Med 1998;17:533-552.

Question 4

A 29-year-old ultramarathoner, who is halfway into a 50-mile race, is sweating profusely. He suddenly collapses, is unresponsive, and has violent muscle contractions. Prior to these symptoms, he had been drinking water at every water stop (every 1 mile). What is the most likely diagnosis?

Explanation

Hyponatremia ("water intoxication") can occur in endurance athletes such as ultramarathoners who are sweating profusely and drinking only water as fluid replacement. Sports drinks which contain electrolytes are a better replacement in this group of athletes. Sodium is the mineral most commonly affected by physical exercise. Sodium concentration in sweat depends on diet, hydration, and heat acclimation. In most cases, sodium lost in sweat can be replaced by regular diet. Potassium plays an important role in nerve conduction and muscle contraction but is not lost in excessive amounts in sweat during exercise. The most frequent loss of potassium is through gastrointestinal disorders or excessive loss from the kidneys. Rehrer reported that overhydrating during very long-lasting exercise in the heat with low or negligible sodium intake can result in reduced performance and hyponatremia. With hyponatremia, the serum sodium is abnormally low, resulting in brain swelling, seizures, coma, and potentially death. Interestingly, hyponatremia is rarely seen in adolescent athletes and young children. Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902.

Question 5

A 12-year-old Little League pitcher reports lateral elbow pain and "catching." Examination reveals painful pronation and supination and tenderness over the lateral elbow. Radiographs are shown in Figures 22a and 22b. Initial management should consist of

Explanation

Osteochondritis of the capitellum is a common problem in young throwing athletes and gymnasts. The mechanism of injury involves lateral compression and axial loading of the capitellum. Repetitive trauma causes ischemia with resultant osteochondral necrosis and sometimes eventual separation. Initial management includes rest for a minimum of 6 weeks; occasionally bracing is used. At long-term follow-up, there is typically an observed radiographic abnormality indicating incomplete healing even in asymptomatic patients. Arthroscopy with in situ drilling is reserved for symptomatic lesions that have an intact articular surface. Lesions with partial separation often require fixation. Lateral column osteotomy is a new investigational procedure designed to relieve lateral compression forces and may be used in salvage cases. Kobayashi K, Burton KJ, Rodner C, et al: Lateral compression injuries in the pediatric elbow: Panner's disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 2004;12:246-254.

Question 6

Medial dislocation of the long head of the biceps tendon in the shoulder is most commonly caused by a

Explanation

Medial dislocation of the biceps tendon in the shoulder is commonly associated with subscapularis tendon tears. Although type II SLAP tears can result in bicipital instability, type I SLAP lesions do not. Congenitally shallow grooves and tears of the transverse ligaments usually do not lead to dislocation of the biceps tendon. Supraspinatus tendon tears are associated with long head of the biceps tendon ruptures but do not cause biceps tendon dislocations. Werner A, Mueller T, Boehm D, et al: The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval: A histoanatomic study. Am J Sports Med 2000;28:28-31.

Question 7

Tension force in the anterior cruciate ligament during passive range of motion is highest at

Explanation

Tension forces in the healthy, as well as the reconstructed, anterior cruciate ligament were measured and found to be highest with the knee in full extension and decreased as the flexion increased. Markolf KL, Burchfield DM, Shapiro MM, et al: Biomechanical consequences of replacement of the anterior cruciate ligament with a patellar ligament allograft. Part II: Forces in the graft compared with forces in the intact ligament. J Bone Joint Surg Am 1996;78:1728-1734.

Question 8

Compared to eumenorrheic athletes, amenorrheic athletes have more frequent occurrences of

Explanation

In secondary amenorrhea, women do not receive the estrogen needed to maintain adequate bone mineralization. This hypoestrogenic state affects bone density, and there is evidence that stress fractures are more frequent in amenorrheic than eumenorrheic athletes. The other conditions are not seen with increased frequency in amenorrheic athletes. Warren MP: Health issues for women athletes: Exercise-induced amenorrhea. J Clin Endocrinol Metab 1999;84:1892-1896.

Question 9

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?

Sports Medicine Board Review 2007: High-Yield MCQs (Set 4) - Figure 4

Explanation

The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction. Fu FH, Bennett CH, Latterman C, et al: Current trends in anterior cruciate ligament reconstruction: Part 1. Biology and biomechanics of reconstruction. Am J Sports Med 1999;27:821-830.

Question 10

A 22-year-old man reports anterior knee pain, swelling, and is unable to perform a straight leg raise after undergoing endoscopic anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft 1 week ago. He is afebrile. Examination reveals a clean incision, moderate effusion, a weak isometric quadriceps contraction, active knee range of motion of 5 degrees to 45 degrees, and the patella is ballottable. Knee radiographs show postoperative changes with good femoral and tibial tunnel placements, and normal patellar height. What is the next most appropriate step in management?

Explanation

Knee pain and swelling in the first week after ACL reconstruction is usually related to a postoperative hemarthrosis. A large hemarthrosis creates capsular distension, which inhibits active quadriceps contraction by a neurologic reflex, the H. reflex. Kennedy and associates reported that an experimentally induced knee effusion at 60 mL was found to result in profound inhibition of reflexly evoked quadriceps contraction. Removal of the hemarthrosis by aspiration will improve strength and often instantaneously restore the ability to contract the quadriceps muscle. A large effusion will also limit knee flexion. EMG and NCVS are not necessary unless there is a high index of suspicion of a femoral neuropathy. Diagnostic ultrasonography is not necessary in this patient but can be useful in the assessment of patellar tendon integrity. MRI is not indicated and would most likely be limited by artifact and postoperative changes. Continuous passive motion is not indicated and would most likely worsen the patient's symptoms. Kennedy JC, Alexander IJ, Hayes KC: Nerve supply of the human knee and its functional importance. Am J Sports Med 1982;10:329-335.

Question 11

A 46-year-old woman fell from her bicycle and sustained the injury shown in Figure 24. Which of the following ligaments has been disrupted?

Sports Medicine Board Review 2007: High-Yield MCQs (Set 4) - Figure 5

Explanation

The radiograph shows a type V acromioclavicular joint injury. Type V injuries involve disruption of the acromioclavicular and coracoclavicular ligaments. Type I injuries involve a sprain of the acromioclavicular joint ligaments. Type II injuries involve disruption of the acromioclavicular joint ligaments; the coracoclavicular ligaments are partially injured. Sternoclavicular ligaments stabilize the medial clavicle and the sternum; they are not damaged with acromioclavicular joint dislocations. Fukuda K, Craig EV, An KN, et al: Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg Am 1986;68:434-439.

Question 12

The use of knee arthroscopy following total knee arthroplasty is most effective in treating which of the following conditions?

Explanation

Patellar clunk syndrome is associated with certain types of posterior stabilized knee arthroplasties. Arthroscopic resection of the band of inflammatory tissue inferior to the patellar component is effective in treating this condition. Arthroscopic lavage of infected knee arthroplasties is not associated with an acceptable success rate. Diagnostic arthroscopy for nonspecific pain following arthroplasty is not uniformly successful. Patellar component maltracking is frequently associated with component malposition and is not alleviated by an arthroscopic lateral release. Synovitis secondary to polyethylene wear is best treated by exchange of the polyethylene spacer and not arthroscopic synovectomy. Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop 1999;367:226-229.

Question 13

Significant anterior tibial translation occurs during which of the following rehabilitation exercises?

Explanation

Terminal non-weight-bearing knee extension exercises from 60 degrees to 0 degrees of flexion increase anterior tibial translation. It is for this reason that this type of exercise should be avoided in the early phase of rehabilitation following anterior cruciate ligament reconstruction so as not to place a tensile strain on the graft. The other rehabilitation exercises either lead to posterior tibial translation in relation to the femur or have no significant effect on tibial translation. Grood ES, Suntay WJ, Noyes FR, et al: Biomechanics of the knee extension exercise: Effect of cutting the anterior cruciate ligament. J Bone Joint Surg Am 1984;66:725-734. Lutz GE, Palmitier RA, An KN: Comparison of tibiofemoral joint forces during open-kinetic-chain and closed-kinetic-chain exercises. J Bone Joint Surg Am 1993;75:732-739.

Question 14

A 22-year-old volleyball player reports the insidious onset of superior and posterior shoulder pain. Radiographs are normal. An MRI scan is shown in Figure 25. What is the most specific physical examination finding?

Sports Medicine Board Review 2007: High-Yield MCQs (Set 4) - Figure 6

Explanation

Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation. Romeo AA, Rotenberg DD, Bach BR Jr: Suprascapular neuropathy. J Am Acad Orthop Surg 1999;7:358-367.

Question 15

A 20-year-old male lacrosse player sustains an anterior dislocation of the shoulder. He is extremely concerned about recurrent dislocations. Which of the following treatments has been shown to reduce the risk of recurrent dislocation?

Explanation

Recent evidence has shown that the position of immobilization of the shoulder after a dislocation influences the reduction of the Bankart lesion. In an MRI study in patients who sustained an anterior dislocation, the Bankart lesion was reduced to the glenoid anatomically with the arm in 30 degrees of external rotation. Subsequently, a clinical follow-up study has shown a reduction in recurrence rates when the arm is immobilized in external rotation compared to internal rotation. Itoi E, Hatakeyama Y, Kido T, et al: A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study. J Shoulder Elbow Surg 2003;12:413-415.

Question 16

A 43-year-old soccer player who had knee pain following a twisting injury underwent an arthroscopic meniscectomy 6 months ago. He continues to report posterior knee pain. Examination reveals soft-tissue fullness and tenderness just above the popliteal fossa, trace knee effusion, full range of knee motion, no instability, and negative meniscal signs. Radiographs show some mild medial joint space narrowing but no other bony changes. What is the next most appropriate step in management?

Explanation

The phenomenon of tumors misdiagnosed as athletic injuries has been termed "sports tumors." Lewis and Reilly presented a series of 36 patients who initially were thought to have a sports-related injury but ultimately were diagnosed with a primary bone tumor, soft-tissue tumor, or tumor-like condition. Muscolo and associates presented a series of 25 tumors that had been previously treated with an intra-articular procedure as a result of a misdiagnosis of an athletic injury. Initial diagnoses included 21 meniscal lesions, one traumatic synovial cyst, one patellofemoral subluxation, one anterior cruciate ligament tear, and one case of nonspecific synovitis. The final diagnoses were a malignant tumor in 14 patients and a benign tumor in 11 patients. The authors noted that oncologic surgical treatment was affected in 15 of the 25 patients. The most frequent causes of erroneous diagnosis were initial poor quality radiographs and an unquestioned original diagnosis despite persistent symptoms. Persistent symptoms warrant further diagnostic studies, not additional treatment such as physical therapy, corticosteroid injection, or an unloader brace. Although a bone scan may be helpful in this case and confirm arthrosis of the medial compartment, the suspicion of a soft-tissue mass makes MRI the imaging modality of choice. Muscolo DL, Ayerza MA, Makino A, et al: Tumors about the knee misdiagnosed as athletic injuries. J Bone Joint Surg Am 2003;85:1209-1214.

Question 17

Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of

Explanation

The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type. Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20. Warner JP, Beim GM, Higgins L: The treatment of symptomatic os acromiale. J Bone Joint Surg Am 1998;80:1320-1326.

Question 18

An 18-year-old rugby player has had pain in his ring finger after missing a tackle 1 week ago. Examination reveals tenderness in the distal palm, and he is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs are normal. What is the most appropriate management?

Explanation

Flexor digitorum profundus rupture or "rugger jersey finger" often occurs in the ring finger after the player misses a tackle and catches the digit on the shirt of the opposing player. Surgical repair is required for zone I-type injuries. Moiemen NS, Elliot D: Primary flexor tendon repair in zone I. J Hand Surg Br 2000;25:78-84.

Question 19

Storage of musculoskeletal allografts by cryopreservation is achieved by

Explanation

Cryopreservation uses chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation. The tissue is procured, cooled to wet ice temperature for quarantine, and then stored in a container with cryoprotectant solution of dimethyl sulfoxide or glycerol which displaces the cellular water. The controlled rate freezing is then done to prevent ice crystal formation. Fresh allografts are not frozen in order to maintain maximum cellular viability, and this process limits the shelf life of osteochondral allografts. Freeze-drying involves replacement of water in the tissue with alcohol to a moisture level of 5% and then uses a vacuum process to remove the alcohol from the tissue. Preparation of fresh frozen grafts involves freezing the graft twice and packaging the tissue without solution at minus 80 degrees C. American Association of Tissue Banks: Standards for Tissue Banking. MacLean, VA, American Association of Tissue Banks, 1999. Vangsness CT Jr, Triffon MJ, Joyce MJ, et al: Soft tissue allograft reconstruction of the human knee: A survey of the American Association of Tissue Banks. Am J Sports Med 1996;24:230-234.

Question 20

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with

Explanation

An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals. Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96.

Question 21

Closed-chain exercise differs from open-chain exercise in which of the following ways?

Explanation

Closed-chain exercise requires the distal portion of the extremity to be fixed. It is more commonly used in lower extremity exercise, and movement is produced by co-contraction of muscles. Joint compression is increased, and multiple joints are involved with closed-chain exercise. In open-chain exercise, the distal portion of the extremity is free. Braddom RL (ed): Physical Medicine and Rehabilitation, ed 2. Philadelphia, PA, Saunders, 2000, pp 975-976.

Question 22

What procedure can eliminate a sulcus sign?

Explanation

A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation. Field LD, Warren RF, O'Brien SJ, et al: Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med 1995;23:557-563.

Question 23

An eversion mechanism of injury is associated with which of the following ankle conditions?

Explanation

An inversion ankle injury typically involves ligamentous damage to the lateral ligaments of the ankle to include the anterior talofibular ligament and calcaneofibular ligament. Acute and particularly chronic ankle sprains also can have associated injuries. The inversion mechanism has been implicated in osteochondral and transchondral talar dome lesions, producing splits in the peroneus tendons, and in the development of meniscoid and soft-tissue impingement lesions in the anterolateral ankle. An inversion mechanism can also stretch the superficial peroneal nerve, leading to pain and paresthesias along its distribution. A fracture of the anterior colliculus is typically the result of an eversion mechanism resulting in a bony avulsion of the deltoid ligament from the anterior colliculus of the medial malleolus. Casillas MM: Ligament injuries of the foot and ankle in the athlete, in DeLee JC, Drez D, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2323-2357.

Question 24

Which of the following anatomic structures are in contact with internal impingement in the throwing athlete?

Explanation

Internal impingement occurs in the late cocking phase of throwing with humeral head abduction and maximal external rotation. It is a physiologic phenomonon occurring in 85% of patients undergoing arthroscopy for various indications in one study. Internal impingement is defined as impingement of the posterior-superior rotator cuff between the humerus and posterior-superior glenoid rim. Symptomatic internal impingement is felt to be due to the frequency and magnitude of the impingement in throwers. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 252.

Question 25

Second impact syndrome (SIS) after head injury is characterized by which of the following?

Explanation

SIS is a devastating but preventable complication of head injury. It occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury. A second, sometimes trivial, head injury can lead to a devastating series of events that can result in sudden death. The symptoms tend to progress rapidly and often involve the brain stem. The prognosis is poor. Cantu RC: Second-impact syndrome. Clin Sports Med 1998;17:37-44. Saunders RL, Harbaugh RE: Second impact in catastrophic contact-sports head trauma. JAMA 1984;252:538-539.

Question 26

A 19-year-old collegiate soccer player sustains a concussion during a match. He is completely asymptomatic at rest 4 days post-injury and has normal neurocognitive testing. What is the correct next step in his management according to the standard stepwise return-to-play guidelines?

Explanation

The stepwise return-to-play protocol begins with light aerobic exercise once the athlete is asymptomatic at rest for 24 to 48 hours. Each subsequent step requires at least 24 hours without symptom recurrence before progressing.

Question 27

In a patient undergoing superior capsular reconstruction (SCR) for an irreparable posterosuperior rotator cuff tear, the graft is primarily designed to act as a static restraint against which abnormal kinematic motion?

Explanation

SCR utilizes a graft attached to the superior glenoid and greater tuberosity to act as a static restraint against superior humeral migration. This restores the glenohumeral fulcrum, optimizing the biomechanical efficiency of the deltoid.

Question 28

A patient presents with a combined grade III posterior cruciate ligament (PCL) injury and posterolateral corner (PLC) injury. During biomechanical testing, isolated sectioning of the popliteofibular ligament would result in maximum increased external tibial rotation at which knee flexion angle?

Explanation

The posterolateral corner structures are the primary restraint to external tibial rotation at 30 degrees of knee flexion. At 90 degrees, the PCL becomes an important secondary restraint to external rotation.

Question 29

Which of the following pathophysiological mechanisms is primarily responsible for the rapid deterioration and high mortality seen in Second Impact Syndrome?

Explanation

Second Impact Syndrome occurs when an athlete sustains a second head injury before initial concussion symptoms resolve. This triggers a catastrophic loss of cerebral autoregulation, causing massive cerebral vascular engorgement, malignant edema, and brain herniation.

Question 30

A 55-year-old laborer has a massive, irreparable subscapularis tendon tear. He presents with severe weakness in internal rotation, a positive belly-press test, and pain. Which of the following tendon transfers is the most appropriate surgical option to restore function?

Explanation

A pectoralis major tendon transfer is the procedure of choice for irreparable subscapularis tears to restore active internal rotation and dynamic anterior joint stability. Latissimus dorsi and lower trapezius transfers are indicated for irreparable posterosuperior (supraspinatus/infraspinatus) tears.

Question 31

Which of the following is the most frequently reported complication associated with the use of a bone-patellar tendon-bone (BPTB) autograft for anterior cruciate ligament (ACL) reconstruction?

Explanation

Anterior knee pain, often related to donor site morbidity, is the most common complication following BPTB autograft ACL reconstruction. Patellar fracture and patellar tendon rupture are severe but rare complications.

Question 32

During the sideline evaluation of an athlete with a suspected concussion, the Vestibular/Ocular Motor Screening (VOMS) tool is utilized. Which of the following is NOT a standard component of this assessment?

Explanation

The VOMS tool assesses vestibular and ocular motor impairments via smooth pursuits, saccades, near point of convergence, VOR, and visual motion sensitivity. OKN testing is not a standard component of this clinical screening tool.

Question 33

When performing an arthroscopic rotator cuff repair, aggressive medial mobilization of a chronically retracted supraspinatus tendon places the suprascapular nerve at greatest risk of traction injury at which anatomic location?

Explanation

The suprascapular nerve is firmly tethered at the suprascapular notch beneath the superior transverse scapular ligament. Excessive medial mobilization (>3 cm) of a retracted supraspinatus tendon risks traction injury to the nerve at this location.

Question 34

In an anatomic posterolateral corner (PLC) reconstruction using the LaPrade technique, the fibular attachment of the fibular collateral ligament (FCL) graft should be placed:

Explanation

The native FCL attaches to the lateral aspect of the fibular head, slightly anterior and distal to the attachment of the popliteofibular ligament and the fibular styloid. Anatomic graft placement here is crucial to restore native kinematics.

Question 35

According to the Goutallier classification evaluated on non-contrast CT or MRI, which stage of fatty infiltration in the rotator cuff musculature represents an equal amount of fat and muscle tissue?

Explanation

Goutallier Stage 3 is characterized by an equal amount of fat and muscle tissue within the muscle belly. Stage 1 has fatty streaks, Stage 2 has more muscle than fat, and Stage 4 has more fat than muscle.

Question 36

A 25-year-old male presents with lateral knee pain after a rugby tackle. The Dial test demonstrates 15 degrees of increased external rotation compared to the contralateral knee at 30 degrees of flexion, but symmetric rotation at 90 degrees of flexion. What is the most likely diagnosis?

Explanation

A positive Dial test (>10 degrees of increased external rotation) at 30 degrees of flexion that normalizes at 90 degrees indicates an isolated posterolateral corner (PLC) injury. An increase at both 30 and 90 degrees suggests a combined PCL and PLC injury.

Question 37

In the immediate sideline assessment of a suspected concussion using the SCAT tool, which of the following findings is considered a 'Red Flag' that necessitates immediate removal from play and emergency medical evaluation?

Explanation

Repeated vomiting is a 'Red Flag' symptom indicating a potential structural brain injury or increasing intracranial pressure, requiring immediate emergency transport. The other symptoms are common in uncomplicated concussions.

Question 38

A 45-year-old overhead throwing athlete undergoes shoulder arthroscopy. A PASTA (Partial Articular Supraspinatus Tendon Avulsion) lesion is identified involving 60% of the tendon footprint. What is the most appropriate management?

Explanation

High-grade articular-sided partial rotator cuff tears (>50% footprint thickness) are generally treated with either tear completion and repair or an in situ repair. Debridement alone is insufficient and leads to high failure rates for tears >50%.

Question 39

A 22-year-old soccer player sustains an isolated Grade III medial collateral ligament (MCL) tear at the femoral insertion. What anatomic characteristic is the primary reason this injury often heals well with nonoperative management?

Explanation

The MCL is an extra-articular structure with a robust blood supply from the superior and inferior medial genicular arteries. This rich vascularity facilitates a strong inflammatory and proliferative healing response, allowing most isolated proximal tears to heal nonoperatively.

Question 40

In the transverse plane of the shoulder, the dynamic glenohumeral force couple that acts to compress and stabilize the humeral head against the glenoid during active motion is primarily formed by the:

Explanation

In the transverse plane, the anterior subscapularis and the posterior infraspinatus and teres minor form a critical force couple. This balances the joint, compressing and centering the humeral head within the glenoid during motion.

Question 41

A 10-year-old female with wide-open physes sustains a complete midsubstance ACL tear. When planning an all-epiphyseal ACL reconstruction, which anatomical structure is at greatest risk of iatrogenic injury during femoral tunnel drilling?

Explanation

In an all-epiphyseal ACL reconstruction for skeletally immature patients, the femoral tunnel must be drilled entirely distal to the distal femoral physis. Errant drilling can cause physeal arrest and subsequent severe angular or leg-length deformities.

Question 42

Which of the following premorbid factors is most strongly associated with a prolonged recovery and the development of Post-Concussion Syndrome (PCS) following a sport-related mild traumatic brain injury?

Explanation

A personal or family history of migraines, learning disabilities, ADHD, anxiety, depression, and female sex are all established pre-injury risk factors for a prolonged recovery and post-concussion syndrome.

Question 43

A 35-year-old overhead athlete undergoes an MRI of the shoulder which reveals a type II SLAP tear and a paralabral cyst located in the spinoglenoid notch. Which isolated physical examination finding is most likely to be present?

Explanation

A paralabral cyst extending into the spinoglenoid notch selectively compresses the distal terminal branch of the suprascapular nerve. This results in isolated denervation of the infraspinatus, presenting clinically as isolated weakness in external rotation.

Question 44

A 29-year-old male sustains a knee dislocation (KD-III) with complete disruption of the ACL, PCL, and MCL. After closed reduction, his ankle-brachial index (ABI) is 0.7. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 following a knee dislocation indicates a high suspicion for a major arterial injury. CT angiography or a formal arteriogram is urgently indicated to accurately diagnose and localize popliteal artery injury before surgical exploration.

Question 45

Following an arthroscopic rotator cuff repair, a patient develops severe, global shoulder stiffness and pain out of proportion to the surgical intervention. Inflammatory markers are completely normal. What is the most effective initial management for this condition?

Explanation

Postoperative adhesive capsulitis following rotator cuff repair is initially best managed conservatively. A short course of oral corticosteroids and a structured physical therapy program focusing on gentle stretching is highly effective and avoids compromising the repair.

Question 46

A 19-year-old college football player suffers a concussion during a game. He is symptom-free at rest 3 days later. Once the athlete is asymptomatic at rest, how many minimum days are required to complete the standard graduated return-to-play protocol before full-contact gameplay?

Explanation

The graduated return-to-play protocol consists of 6 stages. Once asymptomatic (Stage 1), athletes progress through 5 active stages (light aerobic exercise, sport-specific exercise, non-contact drills, full-contact practice, and return to play), with each stage requiring a minimum of 24 hours.

Question 47

Which of the following anterior cruciate ligament (ACL) reconstruction graft choices is most uniquely associated with an increased risk of postoperative patellar fracture?

Explanation

Bone-patellar tendon-bone (BTB) autografts are associated with a specific risk of postoperative patellar fracture due to the bony harvest from the patella. Quadriceps tendon grafts with bone blocks have a much lower relative risk of patellar fracture.

Question 48

A 45-year-old male presents with weakness in external rotation and a massive, retracted posterosuperior rotator cuff tear. Retraction of the supraspinatus tendon medial to the glenoid rim is most likely to cause traction injury to the suprascapular nerve at which of the following anatomical locations?

Explanation

Massive, retracted rotator cuff tears alter the course of the suprascapular nerve. This increases tension primarily at the suprascapular notch due to medial tethering, contributing to nerve dysfunction and subsequent fatty infiltration.

Question 49

A 25-year-old rugby player sustains a blow to the anteromedial aspect of his knee while it is fully extended and his foot is planted. Examination reveals a positive dial test at 30 degrees of knee flexion, but symmetric external rotation at 90 degrees compared to the contralateral side. Which structure is predominantly injured?

Explanation

An isolated injury to the posterolateral corner (PLC) results in increased external rotation (positive dial test) at 30 degrees of flexion compared to the contralateral knee. If both the PLC and PCL were injured, external rotation would be increased at both 30 and 90 degrees of flexion.

Question 50

A 55-year-old smoker undergoes an arthroscopic rotator cuff repair. Nicotine primarily impairs tendon-to-bone healing by downregulating which of the following processes at the repair site?

Explanation

Nicotine impairs tendon-to-bone healing primarily through direct vasoconstriction and by decreasing the expression of VEGF and other angiogenic factors. This leads to diminished neovascularization at the repair site, resulting in higher failure rates.

Question 51

Second impact syndrome, a rare but often fatal complication following a premature return to play after a concussion, is primarily driven by which of the following pathophysiological mechanisms?

Explanation

Second impact syndrome occurs when an athlete sustains a second head injury before symptoms from an initial concussion have completely resolved. This triggers a catastrophic loss of cerebral blood flow autoregulation, resulting in rapid vascular engorgement and fatal brain herniation.

Question 52

During a posterior cruciate ligament (PCL) reconstruction, the surgeon aims to anatomically reconstruct the anterolateral (AL) bundle. Which of the following accurately describes the tensioning pattern of the native AL bundle of the PCL?

Explanation

The PCL consists of the larger anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. The AL bundle is tight in flexion and lax in extension, whereas the PM bundle is tight in extension and lax in flexion.

Question 53

A 28-year-old professional baseball pitcher presents with shoulder pain. MRI arthrography reveals a partial articular-sided supraspinatus tendon avulsion (PASTA) involving 60% of the tendon footprint. After failing nonoperative management, what is the most appropriate surgical treatment?

Explanation

For partial articular-sided rotator cuff tears involving greater than 50% of the tendon thickness (or >3-6 mm of the footprint), surgical repair is indicated. This can be successfully performed via an in situ transtendon repair or by completing the tear and performing a standard repair.

Question 54

A 22-year-old female skier sustains a twisting injury to her knee. Radiographs reveal a small avulsion fracture of the lateral tibial plateau (Segond fracture). This radiographic finding is pathognomonic for a concomitant injury to which of the following structures?

Explanation

A Segond fracture is an avulsion of the anterolateral ligament (ALL) or lateral capsular ligament from the lateral tibial plateau. It is classically associated with an ACL tear, occurring in over 75% to 90% of cases.

Question 55

Superior capsular reconstruction (SCR) is considered for younger patients with massive, irreparable posterosuperior rotator cuff tears. The primary biomechanical goal of this procedure is to prevent which of the following?

Explanation

Superior capsular reconstruction utilizes a graft to replace the deficient superior capsule. The primary biomechanical goal is to depress the humeral head, preventing superior migration and restoring normal glenohumeral kinematics to allow the deltoid to function effectively.

Question 56

Which of the following components of the Sport Concussion Assessment Tool 5 (SCAT5) is specifically designed to evaluate delayed recall?

Explanation

In the SCAT5, delayed recall is tested by asking the athlete to remember and repeat a list of 5 or 10 words that were presented during the immediate memory portion of the cognitive assessment, typically after a 5-minute delay.

Question 57

A 30-year-old male sustains an isolated Grade III medial collateral ligament (MCL) tear of the knee. What is the most appropriate initial management for this injury?

Explanation

The vast majority of isolated Grade III MCL tears heal well with nonoperative management, consisting of a hinged knee brace and early functional rehabilitation. Surgical intervention is typically reserved for multiligamentous injuries, presence of a Stener-like lesion of the MCL, or chronic instability.

Question 58

During the physical examination of a patient with suspected rotator cuff pathology, the examiner performs the "belly-press" test. The patient is unable to maintain pressure on their abdomen without bringing their elbow posterior to the mid-coronal plane. This finding indicates weakness of which muscle?

Explanation

The belly-press test evaluates the integrity of the subscapularis muscle. A positive test occurs when the patient drops their elbow posteriorly to use shoulder extension (latissimus dorsi/posterior deltoid) rather than internal rotation to press against the abdomen.

Question 59

A 28-year-old male is brought to the emergency department after a motorcycle collision with a grossly deformed left knee. Radiographs confirm a knee dislocation. After closed reduction, his pedal pulses are asymmetric. The ankle-brachial index (ABI) on the affected side is 0.75. What is the next most appropriate step in management?

Explanation

In the setting of a knee dislocation, an ABI less than 0.90 or asymmetric pulses warrant advanced vascular imaging, most commonly CT angiography, to evaluate for a popliteal artery injury. Hard signs of vascular injury (e.g., active bleeding, absent pulses) would mandate immediate surgical exploration without delaying for imaging.

Question 60

A 24-year-old athlete sustains a knee injury. On examination, the dial test reveals increased external rotation of the tibia compared to the contralateral side at 30 degrees of knee flexion, but symmetrical external rotation at 90 degrees of knee flexion. This examination finding is most indicative of an isolated injury to which of the following structures?

Explanation

A positive dial test at 30 degrees of flexion that normalizes at 90 degrees indicates an isolated injury to the posterolateral corner (PLC). If the test is positive at both 30 and 90 degrees, it suggests a combined PCL and PLC injury.

Question 61

During arthroscopic rotator cuff repair, an anatomic restoration of the footprint is desired. The normal supraspinatus footprint on the greater tuberosity has an average medial-to-lateral width of approximately:

Explanation

The supraspinatus footprint is triangular and measures approximately 25 mm in the anterior-to-posterior dimension and 14 to 16 mm in the medial-to-lateral dimension. Restoring this medial-to-lateral width is a primary goal of transosseous-equivalent double-row repair.

Question 62

A 16-year-old high school football player is diagnosed with a concussion after a helmet-to-helmet collision. According to the current Consensus Statement on Concussion in Sport, when is the athlete allowed to return to full competition?

Explanation

Current guidelines strictly prohibit same-day return to play for concussed athletes. Return to competition is only permitted after the athlete is asymptomatic and successfully completes a 6-step graduated return-to-play protocol, with each step taking at least 24 hours.

Question 63

A 55-year-old man presents with anterior shoulder pain and weakness. On examination, he is unable to hold his hand pressed against his abdomen when the elbow is brought anterior to the coronal plane. This finding (a positive Bear-hug or Belly-press test) is most sensitive for detecting a tear of which portion of the rotator cuff?

Explanation

The Belly-press and Bear-hug tests are highly sensitive for detecting tears of the upper portion of the subscapularis tendon. The Lift-off test is more specific for tears involving the lower portion of the subscapularis.

Question 64

Second impact syndrome is a rare but potentially fatal complication occurring when a second concussive blow is sustained before full recovery from an initial concussion. The rapid mortality associated with this syndrome is primarily driven by:

Explanation

Second impact syndrome causes a fatal loss of cerebral vascular autoregulation. This leads to massive cerebrovascular engorgement, rapid brain edema, increased intracranial pressure, and uncal herniation.

Question 65

A 22-year-old soccer player presents with a recurrent knee effusion and instability 4 months after an anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone autograft. What is the most common cause of early failure (within 6 months) following ACL reconstruction?

Explanation

The most common cause of early ACL reconstruction failure (less than 6 months postoperatively) is surgical error. Non-anatomic tunnel placement, particularly a femoral tunnel that is placed too far anteriorly, places excessive stress on the graft during flexion.

Question 66

A 68-year-old woman with a massive, retracted rotator cuff tear involving the supraspinatus and entire infraspinatus presents with 'pseudoparalysis' of forward elevation. In the setting of an intact subscapularis, this pseudoparalysis indicates a disruption of which biomechanical force couple?

Explanation

The coronal plane force couple consists of the deltoid (creating a superior sheer force) and the inferior rotator cuff (creating an inferior compressive force). Disruption of the inferior cuff (infraspinatus/teres minor) allows unopposed superior migration by the deltoid, resulting in pseudoparalysis.

Question 67

Which of the following factors is considered the strongest predictor of a prolonged recovery (post-concussion syndrome) following a sports-related concussion?

Explanation

The severity and number of initial symptoms reported in the first few days following a concussion is the most consistent and strongest predictor of a prolonged recovery. Loss of consciousness and amnesia are not strongly predictive of prolonged symptom duration.

Question 68

A radiograph of a 25-year-old skier demonstrates an elliptical cortical avulsion fracture of the lateral aspect of the proximal tibia, just distal to the articular surface (Segond fracture). This radiographic finding is virtually pathognomonic for an injury to which of the following structures?

Explanation

A Segond fracture is an avulsion fracture of the anterolateral capsule/anterolateral ligament from the lateral tibial plateau. It is considered highly specific (pathognomonic) for an ACL tear.

Question 69

When evaluating a patient for a rotator cuff repair, preoperative MRI is used to assess muscle quality via the Goutallier classification. Which Goutallier stage is defined as having equal amounts of fat and muscle within the rotator cuff muscle belly?

Explanation

In the Goutallier classification of fatty infiltration: Stage 1 is some fatty streaks; Stage 2 is more muscle than fat; Stage 3 is equal amounts of fat and muscle; and Stage 4 is more fat than muscle. Stages 3 and 4 generally portend poor structural outcomes after repair.

Question 70

A 21-year-old collegiate hockey player sustains an isolated Grade III tear of the medial collateral ligament (MCL) at its femoral insertion. There is no meniscal or cruciate ligament pathology. What is the most appropriate initial management?

Explanation

Isolated Grade III MCL tears, even those at the femoral insertion, have an excellent capacity for healing non-operatively. The gold standard treatment is a hinged knee brace allowing early controlled range of motion and progressive weight-bearing.

Question 71

The rotator cuff interval is a triangular anatomic space in the anterior shoulder bounded by the supraspinatus superiorly, the subscapularis inferiorly, and the coracoid process medially. Which of the following structures passes through this interval?

Explanation

The rotator cuff interval contains the long head of the biceps tendon, the coracohumeral ligament (CHL), and the superior glenohumeral ligament (SGHL). It is bordered by the supraspinatus, subscapularis, and the base of the coracoid.

Question 72

According to the Canadian CT Head Rule, which of the following is an absolute indication for obtaining a non-contrast CT scan of the head in a 20-year-old concussed athlete with a Glasgow Coma Scale (GCS) score of 15?

Explanation

The Canadian CT Head Rule states that imaging is indicated for high-risk criteria, which include: GCS < 15 at 2 hours post-injury, suspected open or depressed skull fracture, any sign of basal skull fracture, vomiting 2 or more times, or age > 65 years.

Question 73

The posterior cruciate ligament (PCL) is composed of two primary functional bundles. In which position of the knee is the anterolateral (AL) bundle of the PCL at its maximum tension?

Explanation

The anterolateral (AL) bundle of the PCL is the larger bundle and is tightest in knee flexion (around 90 degrees). Conversely, the posteromedial (PM) bundle is tightest in full extension.

Question 74

Superior Capsular Reconstruction (SCR) is a joint-preserving surgical option for massive, irreparable posterosuperior rotator cuff tears. In this procedure, the graft is anchored medially to the superior glenoid and laterally to the:

Explanation

In Superior Capsular Reconstruction (SCR), an allograft or autograft is attached medially to the superior glenoid rim and laterally to the greater tuberosity. This static restraint helps prevent superior migration of the humeral head.

Question 75

A 28-year-old football player sustains a severe varus and hyperextension injury to his knee, resulting in a posterolateral corner (PLC) injury. Post-injury, he complains of numbness over the dorsum of his foot and an inability to dorsiflex his ankle. Which nerve is most likely injured?

Explanation

The common peroneal nerve is highly susceptible to traction injury during a varus and hyperextension insult that damages the posterolateral corner of the knee. Injury to this nerve results in foot drop and paresthesias over the dorsal aspect of the foot.

Question 76

Massive retraction of a supraspinatus tear medial to the glenoid rim significantly increases the risk of traction neuropathy to the suprascapular nerve. At which anatomic location does this traction most commonly tether and compress the nerve?

Explanation

When the supraspinatus tendon retracts medially, it creates an abnormal traction force on the suprascapular nerve as it passes under the transverse scapular ligament at the suprascapular notch. Compression at the spinoglenoid notch more commonly affects the infraspinatus branch only (e.g., from a paralabral cyst).

Question 77

The acute neurometabolic cascade of a sports-related concussion begins immediately following biomechanical injury to the brain. This initial phase is characterized by an abrupt release of excitatory neurotransmitters (like glutamate) and a massive cellular efflux of which ion?

Explanation

The initial neurometabolic cascade in concussion is marked by indiscriminate release of glutamate, leading to massive efflux of intracellular potassium (K+) and influx of calcium (Ca2+). The Na+/K+ pump then requires massive ATP to restore homeostasis, causing a relative energy crisis.

Question 78

The anterolateral ligament (ALL) of the knee has gained attention as an important secondary restraint to internal tibial rotation. From its femoral origin near the lateral epicondyle, where is its primary insertion site on the tibia?

Explanation

The anterolateral ligament (ALL) originates on the lateral femoral epicondyle and inserts on the anterolateral tibia, specifically midway between Gerdy's tubercle and the fibular head. It is a distinct ligamentous structure of the anterolateral capsule.

Question 79

The anterior cruciate ligament (ACL) is anatomically composed of two bundles named for their tibial insertion sites. Which bundle is primarily responsible for rotational stability and is tightest in knee extension?

Explanation

The posterolateral (PL) bundle of the ACL is tightest in full extension and is the primary restraint to rotatory loads (e.g., pivot shift). The anteromedial (AM) bundle is tightest in flexion and primarily restricts anterior tibial translation.

Question 80

A 19-year-old collegiate soccer player sustains a concussion during a game. She undergoes a period of rest and is completely asymptomatic at rest 48 hours later. According to the standard graduated return-to-play protocol, what is the next step in her management?

Explanation

The graduated return-to-play protocol requires players to be completely asymptomatic before beginning. The first active stage following the rest period is light aerobic exercise, which then progresses sequentially to sport-specific exercise, non-contact drills, full-contact practice, and finally normal game play.

Question 81

A 25-year-old rugby player falls directly onto his flexed right knee. Examination reveals a positive posterior drawer test at 90 degrees of flexion. The dial test demonstrates 20 degrees of increased external rotation at 30 degrees of flexion, and 25 degrees of increased external rotation at 90 degrees of flexion compared to the contralateral knee. Which structures are injured?

Explanation

Increased external rotation isolated to 30 degrees of flexion indicates a posterolateral corner (PLC) injury. When the external rotation remains increased at both 30 and 90 degrees of flexion, it indicates a combined PCL and PLC injury.

Question 82

A 35-year-old elite tennis player presents with a PASTA (Partial Articular Supraspinatus Tendon Avulsion) lesion involving 60% of the tendon footprint depth. He has failed 6 months of conservative management. What is the most appropriate surgical treatment?

Explanation

For high-grade articular-sided partial rotator cuff tears (involving >50% of the tendon thickness), surgical intervention typically requires either tear completion and formal repair, or an in situ repair, to adequately restore footprint biomechanics.

Question 83

A high school football player returns to play before completely resolving symptoms from a prior concussion. He sustains a seemingly minor blow to the head and rapidly collapses, progressing to a coma. This catastrophic cascade (Second Impact Syndrome) is primarily driven by:

Explanation

Second Impact Syndrome occurs when a second head injury is sustained before the brain recovers from the first. It causes a catastrophic loss of cerebral autoregulation, leading to rapid vascular engorgement, massive brain swelling, and potential herniation.

Question 84

When utilizing a bone-patellar tendon-bone (BTB) autograft for ACL reconstruction, placing the femoral tunnel too anteriorly (shallow) within the intercondylar notch will result in which of the following kinematic abnormalities?

Explanation

Placing the ACL femoral tunnel too anteriorly (shallow) in the notch results in a graft that becomes excessively tight in flexion and loose in extension, leading to a marked loss of knee flexion.

Question 85

A 72-year-old female presents with pseudoparalysis of the right shoulder and severe pain. Radiographs reveal superior migration of the humeral head with articulation against the acromion. MRI confirms a massive, retracted, irrepairable rotator cuff tear with significant fatty atrophy, but an intact deltoid muscle. What is the most appropriate definitive surgical option?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for rotator cuff tear arthropathy presenting with pseudoparalysis. It medializes and distalizes the center of rotation, allowing the intact deltoid to effectively elevate the arm.

Question 86

A 22-year-old collegiate skier sustains an isolated Grade III MCL tear of the left knee. There is valgus gapping at both 0 and 30 degrees, but ACL and PCL are intact on MRI. Which of the following represents the most widely accepted initial management?

Explanation

Isolated Grade I, II, and the vast majority of Grade III MCL injuries are successfully treated non-operatively. A hinged knee brace that protects against valgus stress while allowing early range of motion yields excellent long-term functional outcomes.

Question 87

Which of the following components of the SCAT5 (Sport Concussion Assessment Tool 5) is utilized specifically to assess an athlete's immediate memory?

Explanation

Immediate memory in the SCAT5 is tested using a word recall test where the examiner reads a list of words and the athlete must repeat back as many as possible. Concentration is assessed differently, typically by reciting digits backwards or months in reverse.

Question 88

A 26-year-old male presents for a revision ACL reconstruction. Preoperative CT scan demonstrates extensive femoral and tibial tunnel osteolysis, with both tunnels measuring 16 mm in diameter. What is the most appropriate next step in management?

Explanation

Tunnel widening greater than 14-15 mm typically necessitates a two-stage revision strategy. The first stage involves hardware removal and bone grafting of the expanded tunnels, followed by the definitive revision ACL reconstruction 4-6 months later once the bone graft has incorporated.

Question 89

During an arthroscopic rotator cuff repair, extensive medial mobilization of a massive, chronically retracted supraspinatus tear is required. Which neurological structure is at greatest risk of injury during this mobilization, particularly if releasing the coracohumeral ligament near the base of the coracoid?

Explanation

The suprascapular nerve is at risk during extensive medial mobilization of the supraspinatus and release around the superior transverse scapular ligament. It courses approximately 1-2 cm medial to the superior glenoid rim at the base of the coracoid process.

Question 90

A 28-year-old male sustains a traumatic knee dislocation (KD-III). Following closed reduction, examination reveals an inability to dorsiflex the foot and numbness over the dorsum of the foot.

Injury to which specific ligamentous complex of the knee is most highly associated with this neurologic deficit?

Explanation

Common peroneal nerve injury presents with foot drop and dorsal foot numbness. It is highly associated with posterolateral corner (PLC) injuries and knee dislocations because the nerve intimately wraps around the fibular neck directly adjacent to the PLC structures.

Question 91

According to the Goutallier classification for rotator cuff fatty infiltration evaluated on MRI, a supraspinatus muscle belly that demonstrates equal amounts of fat and muscle tissue is classified as:

Explanation

In the Goutallier classification, Grade 1 represents fatty streaks; Grade 2 is more muscle than fat; Grade 3 exhibits equal amounts of fat and muscle; and Grade 4 is more fat than muscle. Grades 3 and 4 generally indicate a poor prognosis for successful structural repair.

Question 92

Following a concussive brain injury in an athlete, the initial neurometabolic cascade is characterized by an abrupt and massive release of which neurotransmitter, ultimately leading to a toxic intracellular influx of calcium?

Explanation

The initial phase of a concussion's neurometabolic cascade involves a massive release of the excitatory neurotransmitter glutamate. This triggers an efflux of potassium and an influx of calcium, creating a severe energy crisis due to upregulated Na+/K+ pump activity.

Question 93

A 10-year-old male (Tanner stage 1) sustains a complete ACL tear playing soccer. He has significant subjective instability. To minimize the risk of premature physeal closure and growth arrest, which of the following surgical techniques is most appropriate?

Explanation

In highly active, skeletally immature patients (Tanner stage 1 or 2), all-epiphyseal or physeal-sparing techniques are utilized to prevent drilling across the open growth plates. This minimizes the risk of premature physeal closure and subsequent angular or leg-length deformities.

Question 94

A 45-year-old recreational weightlifter feels a sharp pop in his anterior shoulder during a heavy bench press. Exam reveals increased passive external rotation and a distinctly positive belly-press test.

What other associated pathology must the surgeon be highly suspicious of during arthroscopic evaluation?

Explanation

The clinical findings suggest an acute subscapularis tendon tear. Because the subscapularis forms the medial wall of the bicipital groove and contributes significantly to the biceps sling, its disruption is highly associated with medial subluxation or dislocation of the long head of the biceps tendon.

100 High-Yield Orthopedic MCQs: Shoulder & Elbow | Mock Exam 251

AAOS Sports Medicine MCQs (Set 4): Knee Ligament, Rotator Cuff & Concussion | Board Review

Key Takeaway

AAOS Sports Medicine MCQs (Set 4): Knee Ligament, Rotator Cuff & Concussion | Board Review

Chapter Index